Preservation Of Ligaments Research Articles

Scientific and technical advances in continence recovery following radical prostatectomy

The advent of prostate-specific antigen screening has changed the global epidemiology of prostate cancer, with men being diagnosed with organ-confined cancer at a younger age. Radical prostatectomy with curative intent for these patients, while delivering excellent long-term survival outcomes, still has significant side effects, chiefly postprostatectomy incontinence. Increasing age, shorter pre- and post-operative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations of surgical technique and previous prostate surgery have been reported as negative risk factors for delayed continence recovery and/or permanent incontinence following radical prostatectomy. Significant progress in elucidating the functional anatomy and physiology of the male continence mechanism from cadaveric and videourodynamic studies have enabled surgeons to propose innovative surgical techniques during radical prostatectomy for augmenting continence preservation and early return. These have included optimizing the preservation of urethral rhabdosphincter length; avoiding rhabdosphincter injury; posterior reconstruction of Denonvilliers’ musculofascial plate; preservation of the bladder neck and internal sphincter; bladder neck intussusception; bladder neck mucosal eversion; preservation of the puboprostatic ligaments and arcus tendineus; and preservation of putative nerves supplying the continence mechanism. We review the scientific and technical advances in continence recovery following radical prostatectomy, identify the key principles undergirding early return of continence, highlight various treatment strategies for early and refractory postprostatectomy incontinence and describe our experience with a paradigm of these unified key principles. Increasing application of these principles in computer-aided (robotic), minimally invasive and minimal-access (i.e., single-port or natural orifice transluminal) approaches will hopefully enable patients to derive maximal benefit from curative prostatectomy while experiencing early return of continence in the not too distant future.

Spleen and gastrosplenic ligament preserving distal pancreatectomy under a minimum incision approach assisted by laparoscopy

As a modification of hand-assisted laparoscopic pancreatectomy, we devised a method of spleen and gastrosplenic ligament preserving distal pancreatectomy, in which pancreatic resection is performed under direct vision extracorporeally. The distal pancreas and spleen are pulled out of the peritoneal cavity through the minilaparotomy at the epigastrium following hand-assisted laparoscopic dissection of the distal pancreas. Spleen-preserving pancreatectomy is performed safely under direct vision. The gastrosplenic ligament is also preserved to prevent splenic volvulus after the operation. The transected main pancreatic duct is doubly ligated, and the transected pancreatic stump is sewn manually. The preserved spleen and splenic vessels are placed back in the peritoneal cavity after resection. In the current study (n = 3), overall morbidity rate, including splenic volvulus and pancreatic fistula, was 0%. Preservation of the gastrosplenic ligament and extracorporeal preparation of the transected pancreatic stump under direct vision are useful measures in spleen-preserving distal pancreatectomy under a minimum incision approach assisted by laparoscopy.

Results of an Initial Experience with Custom-fit Positioning Total Knee Arthroplasty in a Series of 48 Patients

The custom-fit approach to total knee arthroplasty in conjunction with removal of osteophytes and preservation of ligaments rapidly returned function; restored motion, stability, and postoperative mechanical axis alignment; effected high patient satisfaction; and had an acceptable clinical outcome.

How to select candidates for lateral unicompartmental prosthesis

Lateral unicompartmental knee arthroplasty (UKA) is a very attractive procedure for elderly population with isolated lateral femorotibial arthritis. A good understanding of the UKA concept is necessary to perform this procedure. The UKA allows preservation of both cruciate ligaments, which more closely mimics the kinematics of a normal knee. The indications for UKA are distinctively different from the indications for a total knee arthroplasty or osteotomy. The patient selection guidelines (unicompartmental arthritis, reducibility of frontal deformity, integrity of cruciate ligaments, and no excessive weight) must be strictly respected to obtain satisfactory results. Surgical attention should be focused on correct positioning of the implant and preserving a hypocorrection of the deformity. Then, UKA is a valuable surgical option in the older less active patients with arthritis grade C or D (without severe cupula). Compared with total knee arthroplasty, this less invasive surgical treatment enables a quicker return to daily activities of life. The aim of this study is to report on our personal experience with this type of prosthesis in isolated lateral unicompartmental arthritis.

Balancing the Posterior Cruciate Ligament During Cruciate-Retaining Fixed and Mobile-Bearing Total Knee Arthroplasty: Description of the Pull-Out Lift-Off and Slide-Back Tests

Total knee arthroplasty (TKA) with posterior cruciate ligament (PCL) preservation is a technically demanding procedure but one that has been associated with excellent long-term results. It is crucial during this procedure that the PCL be placed under appropriate tension such that the kinetic benefits of its retention can be gained and so that the adverse affects of its being excessively tight or lax can be avoided. We describe 2 simple intraoperative tests that assess PCL tension in fixed-and mobile-bearing TKA. Performance of the “pull-out lift-off” (POLO) test in fixed bearing knees and the “slide-back test” in rotating platform knees will assure appropriate PCL tension after TKA by determining that it is neither too loose nor too tight. The authors have previously described the POLO test; however, this publication is no longer in print and, therefore, is not accessible as a reference (Chmell MJ, Scott RD. Balancing the posterior cruciate ligament during cruciate-retaining total knee arthroplasty: description of the POLO test. J Orthop Techniques 1996;4:12.). We therefore deemed it appropriate to once again describe it along with the analogous test for rotating platform TKAs.

Comparison of Posterior-Cruciate Retaining versus Substituting P.F.C. Total Knee Arthroplasty (A Randomized Study)

Purpose: To compare the functional results of posterior cruciate-retaining (PCR) and posterior sub- stituting (PS) replacement in patients undergoing primary total knee arthroplasty (TKA) for osteoarthritis. Materials and Methods: A randomized controlled study was carried out to compare the clinical and radiological outcomes of PCR and PS primary P.F.C. Ⓡ TKA. One hundred and sixty eight patients (188 cases), who had a primary diagnosis of osteoarthritis, and an intact functioning posterior cruciate ligament, were enrolled in this study. The patients were randomized regardless of the level of posterior cruciate ligament preservation. One hundred and eighty eight cases had a minimum 6-year follow-up, which included 96 and 92 cases in the PCR and PS groups, respectively. Results: The Knee Society Score, the Hospital for Special Surgery (HSS) knee rating scores, average flexion contracture and radiologic alignment improved significantly, but there were no significant difference between the two groups. On the other hand, the mean postoperative flexion angles in the PCR and PS knees increased from 114.7 o to 121.2 o and 119.3 o to 131.3 o , respectively (p<0.05). Conclusion: There were no significant differences between PCR and PS TKA in the follow-up knee scores. However, the level of postoperative improvement in further flexion was better in the PS group.

Intrafascial Nerve-Sparing Endoscopic Extraperitoneal Radical Prostatectomy

ObjectivesBased on our recently published anatomic studies, we present the most recent refinement of the endoscopic extraperitoneal radical prostatectomy (EERPE), the intrafascial nerve-sparing EERPE (nsEERPE). MethodsAs part of the intrafascial technique, the dissection plane is directly on the prostatic capsule, freeing the prostate laterally from its thin surrounding fascia that contains small vessels and nerves. The technique enables puboprostatic ligament preservation, leaving intact endopelvic fascia, periprostatic fascia, and neurovascular bundles. The operation was performed in 150 patients with indications for nerve-sparing procedure. ResultsThe mean operative time was 131min (range: 50–210min) and the mean catheterization time was 5.9 d (range: 4–20 d). Twelve months postoperatively, 94.3% of the patients were continent (no need for pads), 4.6% had minimal stress incontinence, and one patient required >2pads/d. At the 12-mo follow-up, the potency rates (erections sufficient for intercourse with or without the use of phosphodiesterase 5 [PDE5] inhibitors) of the patients who underwent bilateral intrafascial nsEERPE were 89.7% (age: 44–55 yr), 81.1% (age: 56–65 yr), and 61.9% (age: >65 yr). Positive surgical margins in pT2 and pT3 tumors were 4.5% and 29.4%, respectively. ConclusionsThe intrafascial nsEERPE enables the dissection of the prostate with limited trauma to the surrounding fascias and the enclosed neurovascular bundles. We propose that the preserved neurovascular bundles with intrafascial nsEERPE are more viable. The results advocate this proposition.

Primary osteoarthritis of the elbow: Lack of radiographic evidence for morphologic predisposition, results of operative debridement at intermediate follow-up, and basis for a new radiographic classification system

This study evaluated whether or not a morphologic predisposition exists to the development of primary osteoarthritis and establishes a classification tool to predict outcome in surgical treatment of elbow osteoarthritis. Detailed radiographic morphologic analysis of the ulnotrochlear and radio-capitellar joints in 90 normal and 24 osteoarthritic elbows showed few differences. Based upon commonly demonstrated radiographic features of degenerative changes, joint space narrowing, and marginal osteophytes, a classification system for rating the severity of primary osteoarthritis of the elbow was developed and applied retrospectively classified the preoperative radiographs of 18 patients (21 elbows) who had undergone elbow debridement and capsular release through a lateral collateral ligament preserving approach. Clinical and radiographic outcomes were assessed at an average 65 months postoperative. Total elbow motion and Mayo elbow performance scores were best in those who had been classified as class I preoperatively and worst in those in class III. This newly developed radiographic classification system is a useful tool in predicting surgical outcome following debridement of primary elbow osteoarthritis.

The Dorsal Approach to Silicone Implant Arthroplasty of the Proximal Interphalangeal Joint

Silicone implant arthroplasty (SIA) has been an effective alternative in the treatment of arthritic conditions of the proximal interphalangeal (PIP) joints since its introduction into surgical practice in the early 1960s. Patients with post-traumatic, degenerative, and rheumatoid arthritis all may be candidates for PIP joint SIA. The indications for SIA of the PIP joint include pain, limited joint mobility, and angular deformity of the joint with underlying articular destruction. Contraindications include ankylosis of the joint due to bony or soft-tissue restrictions, infection, inadequate soft-tissue support for coverage, absence of flexor and/or extensor tendon function, and considerable periarticular bone loss in the proximal and middle phalanges. Proximal interphalangeal joint SIA can be accomplished by dorsal, volar, or midaxial approaches. The dorsal approach has the advantages of relative technical ease, excellent visibility of the articular surfaces for preparation of the implant canals, access to the extensor mechanism for correction of central slip abnormalities, and preservation of the collateral ligaments. The surgical technique is outlined and includes handling of the extensor mechanism and central slip attachment, mobilization of the collateral ligaments, joint surface resection, preparation of the bony canals, implant sizing, implant insertion, and repair of the soft tissues. Pearls and pitfalls of the technique are outlined. Early postoperative mobilization with hand therapy is essential but must include protection of the repaired extensor apparatus. Complications include bony changes, implant failure, recurrent angular deviation or swan-neck deformity, particulate synovitis, and rarely, infection. Complications related to implant failure are most often managed with implant replacement or arthrodesis; those related to poor mobility, angular deformity and tendon imbalance, pain, or infection are managed by arthrodesis. Although SIA of the PIP joint has a relatively high degree of success when measured both subjectively and objectively, careful patient selection is important for achieving desirable results.

Kinematik des Metakarpophalangeal-Gelenks nach Implantation der Oberflächenersatzprothese

Prosthetic replacement in the hand must address such unique challenges as preservation of the collateral ligaments, tendon balancing,and Stability. Surface replacement arthroplasty can be an alternative to other current implants. The purpose of this study was to evaluate the metacarpophalangeal joint kinematics after surface replacement arthroplasty. The kinematics of pyrolytic carbon as a surface replacement implant for the metacarpophalangeal joint (MCP) was compared with the intact MCP joint in eight fresh cadaver long fingers by means of an electromagnetic tracking system (Polhemus, Colchester, VT). The eight human cadaver MCP joints were tested before implantation, after implantation, after collateral ligaments resection, and after collateral ligaments reconstruction. The kinematics of the MCP joint is reproduced by the joint surface replacement arthroplasty when normal ligament tension was present. The maximum angular displacement of the pyrocarbon implant was 378 for lateral deviation and 338 for rotation during the passive flexion and extension motion. The instantaneus center of rotation (ICR) after implant insertion was nearly identical to the center of rotation of the normal joint. The results also indicated that the collateral ligaments provide the primary stability of the MCP joint. No significant differences in lateral and rotational stability after surface replacement arthroplasty were noted. While collateral ligaments resection significantly affected the stability of the MCP joint. The ICR of the pyrocarbon implant most closely matched that of the intact MCP joint. The pyrocarbon implant provides suitable stability to radio-ulnar deviation and rotational stresses as a resurfacing implant and it simulates the kinematics of the intact MCP joint. By using new materials and taking the anatomical and biomechanical requirements into consideration, the endoprosthesis of the finger joints has created an option to achieve good long-term results. The inadequate results of earlier and current prostheses are a consequence of their mechanical construction and their materials. The success of the new implants could be proven by preferably long-term, controlled studies.

Resection Rectopexy for External Rectal Prolapse Reduces Constipation and Anal Incontinence

The main aim was to examine constipation and anal incontinence in patients before and after resection for external rectal prolapse. Twenty patients had ligament preserving suture rectopexy and sigmoid resection (resection rectopexy) for external rectal prolapse by laparoscopic (n = 15) or open (n = 5) technique during 2001-2005. They were prospectively evaluated for constipation and anal incontinence using validated incontinence and KESS-constipation scores. Constipation score was significantly reduced from mean 7.7 (5.4-9.9) to 4.5 (2.5-6.4) after median 4 months (1-19) and to 4.3 (2.2-6.3) after median 17 months (4-51). Six and four patients were constipated preoperatively and 17 months postoperatively, respectively. The four symptoms feeling incomplete evacuation of stool, minutes in lavatory per attempt, use of enemas/digitation and painful evacuation effort were significantly reduced, whilst stool consistency increased. Fourteen patients (70%) had anal incontinence. Corresponding and significant reduction in their scores were from mean 12.5 (9.4-15.5) to 5.1 (2.1-8.1) and to 3.6 (1.3-5.9). Incontinence was improved in 13 and unaltered in one patient(s). Two patients with worse outcome had increased stool consistency and constipation scores. Resection rectopexy for rectal prolapse reduced anal incontinence and constipation.

Prospective Evaluation of Feminizing Genitoplasty Using Partial Urogenital Sinus Mobilization for Congenital Adrenal Hyperplasia

We present our experience with partial urogenital sinus mobilization in girls with congenital adrenal hyperplasia, with particular attention to vaginal caliber, introitus position, urinary continence and genital appearance. We present data on a prospective evaluation of 24 girls with congenital adrenal hyperplasia who underwent feminizing genitoplasty using urogenital sinus mobilization with preservation of the pubourethral ligaments during a 4-year period. Urogenital sinus length determined by cystoscopy and degree of external genitalia virilization, defined according to Prader classification, were evaluated before reconstruction. At followup patients were examined while under sedation for evaluation of overall external genitalia cosmesis and calibration of the vagina. Urinary continence status and voiding efficiency were assessed clinically in toilet trained patients by voiding diary, and measurement of bladder capacity and post-void residual by ultrasound. Patient age at operation ranged from 1 to 16 years (median 28.5 months), with a mean followup of 25 months (8 to 47). Degree of virilization was Prader type III in 3 children (12.5%), type IV in 16 (66.7%) and type V in 5 (20.8%). Urogenital sinus length was 2.5 cm or less in 17 children. Cosmetic results were good in 21 patients (87.5%) and satisfactory in 3 (12.5%). The vaginal and urethral openings were separate and identified at the surface of the vestibule in 21 girls. Adequate caliber of the mobilized vagina was achieved in 23 patients (95.8%). None of the 20 toilet trained children had urinary incontinence or recurrent urinary tract infections, with normal bladder emptying in 18 and small post-void residual in 2 (10%). Urinary continence and excellent cosmetic appearance with adequate exteriorization of the vaginal and urethral openings can be achieved in most children with urogenital sinus anomaly treated with partial urogenital sinus mobilization.

Surgery for Rectal Prolapse: Orr-Loygue Ventral Rectopexy With Limited Dissection Prevents Postoperative-Induced Constipation Without Increasing Recurrence

Abdominal rectopexy is the preferred surgical technique for the treatment of total rectal prolapse. In many reported series, its results are impaired by induced constipation. Lateral rectal ligaments preservation could prevent constipation but increase recurrence rates. We report anatomic and functional results of abdominal Orr-Loygue ventral rectopexy with dissection limited to anterior and posterior rectal wall. Consecutive patients with total rectal prolapse or intra-anal rectal prolapse associated to fecal incontinence or outlet obstruction were treated by abdominal rectopexy. Recurrences, correction of symptoms, and induced constipation were prospectively analyzed. Seventy-three patients were treated between 1993 and 2004. Recurrence was observed in 3 of 73 patients (4.1 percent) after a mean follow-up period of 28.6 (range, 6-84) months. Overall patient satisfaction (correction of prolapse, incontinence, and/or outlet obstruction) after the procedure was classified in three categories: Cured: n = 45 (61.6 percent); Improved: n = 24 (32.9 percent); Failure: n = 4 (5.5 percent). Postoperative constipation appeared in 2 of 36 (5.5 percent) preoperatively nonconstipated patients and worsened in 2 of 37 (5.4 percent) preoperatively constipated patients. Orr-Loygue abdominal ventral rectopexy with limited dissection and preservation of rectal lateral ligaments is a safe and effective procedure for the treatment of complete rectal prolapse, or internal prolapse associated with fecal incontinence or outlet obstruction. Preservation of lateral ligaments seems to prevent postoperative constipation without increasing the risk of prolapse recurrence.

Analysis of the Relationship between Posterior Cruciate Ligament Preservation and Femoral Component Sizein Total Knee Arthroplasty

Purpose : How PCL preservation affects the selection of femoral component size in total knee arthroplasty. Materials and Methods: One hundred and fifty-seven patients, two-hundred and twenty-two knees, underwent total knee arthroplasties with Scorpio®. One hundred and eighteen knees underwent PCLpreserving procedures, and one-hundred and four knees underwent PCL-substituting procedures. For minimization of error, we performed soft tissue balancing and then bone cutting by a Linker system with certain posterior slope (≤3˚). We compared the sizes of the femoral components between the PCL-preserving and PCL-substituting procedures in order to determine how flexion gap differences affect femoral component sizes (Wilcoxon signed rank test). Results : With a certain minimal posterior slope (≤3˚), the PCL-preservation procedure led to selection of a 2.4 mm smaller femoral component than the PCL substituting procedure (p＜0.05). Conclusion : Selection of femoral component size was affected by PCL preservation, and the size of the femoral component was decreased in the PCL preservation group.

Intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy

Objectives To present a modification of our previously published technique of nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE). Methods The technique enables puboprostatic ligament preservation, leaving intact the puboprostatic ligaments, endopelvic fascia, periprostatic fascia, and neurovascular bundles (intrafascial dissection). The modification of nsEERPE was performed in 50 consecutive patients. Results The total operative time was 131 minutes (range 75 to 165). The mean catheterization time was 5.4 days (range 5 to 14). Conclusions The intrafascial nsEERPE is a modification of our previously published standard nsEERPE. The anterior approach to the periprostatic fascia enables less traumatic dissection from the prostate and thus, theoretically, a more viable neurovascular bundle.

Laparoscopic Treatment of Liver Hemangioma

Cavernous hemangioma is the most common benign liver tumor. When it becomes symptomatic, enucleation is considered the treatment of choice because of its lower morbidity compared with liver resection. Therefore, although there have been many series of laparoscopic liver resection, only a few cases of laparoscopic enucleation of liver hemangiomas have been reported. We report the case of a 36-year-old woman with a symptomatic 4-cm liver hemangioma of the left lobe who underwent laparoscopic enucleation, with complete relief of the symptoms at the 3-month follow-up. The operating time was 90 minutes. Neither liver mobilization nor ligament division was necessary. The dissection was carried out with minimal blood loss. The postoperative period was uneventful, and the patient was discharged on postoperative day 4. Laparoscopic enucleation is easy to perform in suitable lesions, and its advantage with respect to liver resection is the preservation of healthy parenchyma and liver ligaments. No outflow occlusion is needed, and the intraoperative bleeding is easily controlled. Technical aspects of laparoscopic enucleation are described and a review of the literature is also provided.

Nerve Sparing Endoscopic Extraperitoneal Radical Prostatectomy– Effect of Puboprostatic Ligament Preservation on Early Continence and Positive Margins

IntroductionA technical modification of nerve sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with preservation of the puboprostatic ligaments is presented and compared to a previous techniique. Materials and methodsnsEERPE was performed in 100 men with clinically localized adenocarcinoma of the prostate from March 2004 through February 2005. Patients were divided into two groups: Group A included patients in whom a standard nsEERPE was performed (n=50), and group B included patients in whom a puboprostatic ligament sparing nsEERPE was performed (n=50). The postoperative follow-up was 2 weeks and 3 months evaluating preliminary effects on early continence and positive margins. ResultsThe early return to continence at 2 weeks postoperatively was achieved by 6 patients (12%) in group A, and 12 patients (24%) in group B. Three months after the procedure 24 (48%) and 38 (76%) patients were continent, in groups A and B respectively. Cli.nical outcome (early continence) was significantly better for Group B patients, at 2 weeks (chi-square test, p=0.0019) and at 3 months (chi-square test, p=0.0347) following surgery. No cases of complete or severe incontinence (more than 5pads/day) were observed at 3 months after surgery, in either groups. Groups A and B did not exhibit significant differences regarding their histological status. In group A, positive margins were detected in 6.5% and 26.3% of patients with pT2 and pT3, respectively. In group B, positive margins were found in 3.2% and 15.8% of patients with pT2 and pT3, respectively ConclusionWe propose the use of puboprostatic ligament-sparing nsEERPE as an intriguing method to ascertain recuperation of early continence after nerve sparing procedures, without hindering the final oncological outcome

Clinical and functional comparison of uni- and bicondylar sledge prostheses

The aim of the present study was the evaluation of differences in clinical results, proprioceptive performance and gait in patients with unicondylar and bicondylar sledge prostheses of the knee. In a retrospective study, 17 patients with unicondylar sledge prostheses were compared with 15 patients with bicondylar sledge prostheses. Clinical examination was rated using HSS, Knee Society, and patellar scores and a visual analogue scale for pain. Proprioceptive performance was examined using sway measurements during single leg stance on a force platform. In addition, the patients underwent 3-D gait analysis including measurements of ground reaction forces and surface electromyographic (EMG) investigation of the lower extremity. Comparing both patient groups in clinical scores, gait, EMG and proprioception, no significant differences were found. Implantation of bicondylar sledge prostheses retaining both cruciate ligaments achieves functional results as good as unicompartmental arthroplasty. The presented results might encourage future research on new models of total joint replacement with preservation of both cruciate ligaments.

New-generation implant arthroplasties of the finger joints.

Prosthetic replacement in the hand must address such unique challenges as preservation of the collateral ligaments, tendon balancing, and stability. Some recently developed implant arthroplasties of the metacarpophalangeal and proximal interphalangeal joints have anatomically designed articular components; others have non-cemented, press-fit, carefully contoured intramedullary stems. The rationale behind developing the unlinked or semiconstrained prosthesis with anatomic geometry is that it would create balanced forces across the joint. Low-profile, anatomically designed implants limit the amount of bone removed and preserve the integrity of the collateral ligaments. A metacarpophalangeal joint implant with an elliptical metacarpal head and a nonfixed center of rotation can enhance stability in flexion through greater articular contact. A proximal interphalangeal joint implant that preserves the collateral ligaments also can achieve improved stability. Component loosening is not an early complication with these recent designs, and arc of motion is satisfactory.

Paper #137 Minimally invasive treatment of medial compartment osteoarthritis of the knee using a polyurethane spacer: a new technique

Unicondylar arthroplasty (UKA), an almost forgotten option for the arthritic knee, has experienced a resurgence of interest with the Introduction of minimally invasive surgery (ENGH 2002). SCULCO (1994) described UKA as treatment of choice in unicompartmental arthritis of the knee, when arthroplasty is indicated. Advantages over total knee arthroplasty (TKA) are preservation of cruciate ligaments as well as other undamaged structures along with possible restoration of knee function to nearly normal. Patellar dislocation is not necessary as part of the procedure, and hospitalisation can be avoided. We report an extension of UKA using an even less invasive surgical technique to insert a spacer between the femur and tibia for treatment of medial compartment osteoarthritis.